When Deviants Do Good

Jerry and Monique Sternin and their son were among the very first Americans to move to Hanoi when they arrived in Vietnam in 1990. They had come from the Philippines, where Jerry had been director of Save the Children’s program there.

At the time, Vietnam was losing its imports of subsidized rice from ideological backers and shifting from collectivized to private agriculture. The dislocation was deadly — “a near-famine situation,” Monique Sternin said in an interview from Addis Ababa this weekend. About two-thirds of children were malnourished. International feeding programs had helped, but when the programs ended, villages fell back into hunger. The government had asked Save the Children to try to find a lasting solution. Some officials didn’t like having Westerners brought in. You have six months to show results, the government warned. If you don’t, you’re out.

The Sternins had seen in their previous work how big programs run by outsiders created dependency. “The essence of development is to help people build capacity to do things themselves,” said Monique (Jerry died in 2008). “We were struggling to find something.”

They had just read a book, however, by Marian Zeitlin, a professor of nutrition at Tufts University, called “Positive Deviance in Nutrition.” The word deviant usually has negative connotations, but Zeitlin wrote about children who thrived even as those around them were poorly nourished. Zeitlin suggested that nutrition could be improved if a village looked at what these children’s families were doing right.

The Sternins were not experts in fighting malnutrition. But they thought they knew where to find some.They went into villages and asked for volunteers to weigh all children under 3, and to characterize each family’s level of income. The volunteers concluded the obvious: the poorer the family, the more likely the children would be malnourished. Then the Sternins asked if any of the families characterized as “very, very poor” had well-nourished children.

The volunteers checked the list and excitedly reported that there were some.

“So it’s possible for a very, very poor child in the village to be well nourished?” asked the Sternins.

“Let’s go see what their families are doing differently,” the volunteers said.

The volunteers fanned out to interview these “positive deviant” families — in each village there were a few, perhaps 5 or 6. They found several practices in common. Children in the village were fed twice a day, mostly rice. Local custom held that an adult diet was harmful for young children. But the positive deviant parents were collecting tiny crabs or shrimps from rice paddies and giving them to the children along with the greens from sweet potatoes. While village wisdom held that you don’t feed a child who has diarrhea, the positive deviant families did. They also fed their children often throughout the day, and washed their children’s hands before they ate.

The Sternins knew that helping villagers to learn about these deviant behaviors would not be enough. “Knowledge doesn’t change behavior,” said Monique. “Practice changes behavior.” They convened meetings of villagers to discuss how best to spread the behaviors. The villagers decided that parents of malnourished children would gather with their children daily at a neighbor’s house for two weeks. Each family had to collect a handful of shrimps, crabs or greens and bring it to the gathering. With a trained health volunteer, the families cooked meals using the nutritious foods and tried out the new practices. If they didn’t become habit and the children were still malnourished, the families could do another two-week cycle the next month. “Trying something new always makes you a little scared. People got confidence through their peers,” said Monique.

Five and a half months after the Sternins had arrived in Vietnam, authorities weighed the children in the district who had participated in the program. More than 40 percent were now well nourished, and another 20 percent had moved from severe to moderate malnutrition. The Sternins got their visa extended. Vietnam eventually replicated the program in 250 communities.

Poor-country development usually works like this: Outsiders come into a community where there is a problem. They bring in “best practice” ideas that have worked elsewhere, and design ways to teach the community to change its culture and adopt these new ideas.

And then they leave.

If they come back later, however, they might find that not much has changed: a few people adopted the new idea, but not many. And since that was not the way the community did things, even those adventurous few might abandon their new practices.

Here’s how the positive deviance approach is different:

* Outsiders don’t bring in ideas to change a community’s culture. Instead, they ask the community to look for its own members who are having success. Those local ideas, by definition, are affordable and locally acceptable — at least to some people in the community. Since they spring from a community’s DNA, the community is less likely to feel threatened by these ideas and more likely to adopt them.

* The focus is not a community’s problems, but its strengths.

* Outsiders don’t design a communication or training strategy to teach the idea. Outsiders can bring people in the community into one room, but local people design a way to spread the new behaviors.

* Local leaders are not the ones who come up with solutions. That is the job of everyone on the front line dealing with the problem. The leaders’ job is to facilitate the process of finding and spreading these solutions.

* Outsiders don’t monitor success. They show people in the community how to do that. “If they see that things are getting better, that’s further incentive to continue the new behavior,” said Monique.

Positive deviance has now been used in dozens of countries to attack a wide variety of problems. The nutrition program has been replicated all over the world — in each place using different, local solutions. Positive deviance has helped to reduce rates of female genital mutilation in Egypt, improved prisons in Denmark, helped the mentally ill in Pittsburgh strengthen social connections and cut infections at Veterans Affairs hospitals across the United States. Tufts University is host to the Positive Deviance Initiative, which has a staff of four and several consultants who teach the process around the world (Monique is a senior consultant), and the Sternins wrote a book, “The Power of Positive Deviance.”

In 1997, the Pittsburgh Regional Healthcare Initiative was formed to try to improve hospital care. One of its goals was to reduce the infection rate of MRSA, a deadly resistant form of staph, in local hospitals. The city’s V.A. Pittsburgh Healthcare System agreed to run a pilot program beginning in 2001, adopting the Toyota Production System. (Paul O’Neill, the former treasury secretary, was one founder of the Initiative; he had used Toyota’s manufacturing and logistics strategies when he ran Alcoa.) “This went a long way in solving some of the technical problems — providing soap, gowns and gloves where they were needed in quantities they were needed,“ said Jon Lloyd, a prominent Pittsburgh surgeon. “But the so-called behavioral problems were untouched. Once resources were withdrawn from the Toyota model it fell apart. The frontline staff didn’t own it. Physicians, especially, were not washing their hands — nurses were at 70 percent for hand hygiene, but physicians were at 15 percent.”

Lloyd read an article in Fast Company about positive deviance, and invited Jerry Sternin to come speak. He agreed, with the condition that Lloyd produce everyone in the hospital who touched patients in any way. In July 2005, Jerry asked those 150 people who they felt was responsible for preventing infection; they pointed to nurses and the hospital’s infection control officers.

“Six months later Jerry asked the same question, and every hand went up,” said Lloyd, who became the hospital’s positive deviance adviser and coach, and now does the same with other Pittsburgh organizations. “The housekeepers at the VA turned out to be world authorities on infection prevention — people who are never asked for their opinions.”

Ideas came from all over. Edward Yates, on the housekeeping staff, was a wellspring of anti-infection ideas; his unit chose him to brief the staff (including high-ranking doctors) on the unit’s progress. One hospital pastor told his colleagues that he kept his Bible from spreading germs by gowning it with paper hats. He changed the hat with each new patient.

Lloyd said that the other pastors began to do the same. “No one had to tell the others to do this,” he said. “There was just a quiet understanding of a solution that came from somebody who shared their professional DNA.”

Six months later, the infection rate had fallen by more than half, and the gains did not go away. (Since this was not a randomized control trial, there’s no way to know how much of the gains came from the use of positive deviance.) The V.A. then adopted these changes in virtually all its hospitals, recommending that hospitals use the positive deviance approach and offering training in it. From October 2007 to June 2010, MRSA infections in intensive care units at the 153 V.A. hospitals in the program dropped by 65 percent; in nonintensive care units they dropped by 45 percent. (Again, we don’t know if the intervention can take credit, although it is significant that there had been no change in MRSA infection rates during the two years before the intervention.)

Pittsburgh’s experience, ultimately successful, also shows why positive deviance can fail. “It’s particularly difficult for donors who want to have a clear sense of what outcomes will be,” said Roger Swartz, the executive director of the Positive Deviance Initiative. Donors have solutions they like, and they will finance programs that use those solutions. But with positive deviance, you don’t know what the solution will be; it has to emerge as part of the process.

The approach can also be threatening to people at the top. They are used to being the experts, but with positive deviance, it’s the people in the field who are the experts. In hierarchical institutions like hospitals, housekeeping staff members do not usually brief physicians. But where managers can accept revolutionary new ways of doing business, positive deviance can succeed. “I don’t know how this is going to work,” the Pittsburgh V.A. chief Rajiv Jain told his workers when they began the program. “But I have total confidence that you as the front line staff will know.”

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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”